American doctors are accusing America’s health insurance giants of causing deadly delays to medical procedures and essential care – and of putting profits ahead of the health of their patients.
Companies including United Healthcare denied basic analyzes and took months to reconsider, according to doctors who spoke to The Guardian.
“There is good evidence that these types of delays are literally killing people,” said Dr. Ed Weisbart, former chief medical officer of Express Scripts, one of the largest prescription benefit managers in the United States. . “For some people, it’s not just an inconvenience and an annoyance and an aggravation.
“It’s a death sentence, and the only reason insurance companies do it is to maximize their profits. The fact that they can kill you is not in the equation of what they care about. »
Americans spend the most on health care in the industrialized world – a estimated $4.9T in 2023 – but have the worst health outcomes, according to analysis by the Commonwealth Fund.
THE Shot by UnitedHealthcare CEO Brian Thompson Last month prompted a effusion of public anger towards the healthcare industry. While private insurers bring in billions in profits each year, many patients – and their doctors – struggle to navigate a complex financial system to get what they need.
Insurance company lobbyists insist they are “working to protect” people from higher costs and emphasize that everyone in the space, including doctors, is responsible for making US Healthcare Systems are more affordable and easier to navigate.
But in a series of interviews, medical professionals described their frustration with a powerful industry that had prevented them from helping patients.
‘We are stuck in this terrible, vicious cycle’
Dr. Cheryl Kunis, a board member at Physicians for a National Health Program and a nephrologist in New York, always thinks about what happened when one of her patients needed a PET scan. He had a tumor, and before deciding how to treat it, Kunis and his colleagues wanted to establish whether it had spread.
“The surgeon was very honest that he only wanted to operate if the tumor was localized, and without the PET he really wouldn’t be able to make that decision,” Kunis said. “The surgeon and his office, as well as my office, spent hours on the phone. We were talking to someone who was sitting at UnitedHealthCare in front of a computer screen who really didn’t know the underlying medical problem or the test we’re ordering from the patient. »
After an initial refusal, the patient’s appeal for the analysis was finally approved six months later. By then the patient was dead.
“We assume that if he had been diagnosed earlier, he might have been able to do better,” Kunis said. “There’s no way to prove it, but there was a reasonable chance he would have been in better shape if there hadn’t been a six-month delay in getting the scan.”
The health care system is “really stuck in this terrible, vicious cycle,” she said, “with prices constantly rising, lack of regulation and insurance companies unfortunately having leverage over patients who try to receive care.”
‘It’s both demoralizing and insulting’
Health insurance companies often require “peer-to-peer” reviews, where doctors are required to speak with a medical representative from a health insurance company to justify treatment. But insurance representatives are often much less experienced, according to doctors who spoke to The Guardian, and may not even have training in the specific area they were weighing in on.
“When I engage in ‘peer’ review, the peer is never a physician who has my training,” said Dr. Philip Verhoef, an intensive care unit physician based in Honolulu, Hawaii, and former president of Physicians for National Health for National Health for National Health for National Health for National Health for National Health Program. “It’s kind of a joke to even call it ‘Peer to Peer.’ I’ve never had a “peer” conversation that was actually with a real peer. »
Instead, representatives are “second-guessing our judgment as clinicians,” he asserted. “To be completely clear, I have no financial incentive to admit patients to the ICU. It’s both demoralizing and insulting when a bureaucrat somewhere reviews a submitted hospital claim and says, “The decision to admit to the ICU was wrong.” »
Verhoef said he often sees patients enter the intensive care unit for preventable illnesses caused by health insurance company refusals, such as refusal to cover required medications, like insulin or an inhaler for asthma.
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“When people need to use their private health insurance, it actually fails them,” he added. “Insurance is supposed to be there to cover you from financial calamity, when unfortunate things happen, and the current system that we have based on private health insurance has really failed everyone. I don’t think we’re going to regulate our way out of this mess. »
According to Weisbart, a large portion of patients experiencing friction when seeking medical care or assistance is fundamental to insurance practices’ business models. “They don’t care about you, and they see you as an expense, not someone whose health needs to be improved,” he said. “The healthier you are, the more they want you to have them as insurance, and the sicker you are, the more comfortable they are with you being dissatisfied and looking for another insurance company.
“Once they have that money, any time someone has to get health care, it’s just an expense they don’t want to give up.”
The insurance industry’s profits revolve around the delay and denial of medical care, Weisbart said. “When they delay your care for a day, a week, a month or deny it altogether, that’s not a random event,” he said. “This is a business strategy calculated to maximize their profits.”
‘The problem is getting much worse’
Many doctors have recently expressed similar problems with private insurers. Doctors are “forced to become insurance experts on top of our medical expertise, spending countless hours on paperwork instead of patient care,” Dr. Bayo Curry-Winchell of Nevada wrote in a article For Katie Couric Media, while Dr. Claudia Fagan, Cook County Health’s chief medical officer, wrote in a article For common dreams that she had “seen patients suffer and die in order to pay off the bottom lines of corporate health insurers – and in recent years, I have seen this problem get worse.”
UnitedHealthCare did not respond to multiple requests for comment. Ahip, an industry lobby group, said in an emailed statement: “In the fragmented and heavily regulated health care system, health plans, providers and drug manufacturers share responsibility for providing care. high-quality products that are as affordable as possible and easier to navigate for the people we collectively serve. Health plans are working to protect patients from the full impact of rising costs while connecting them to care that is safe, evidence-based and coordinated. »
Doctors who spoke to The Guardian suggested fixing the problems with the US healthcare system will need more than tinkering around the edges.
Weisbart and Verhoef argued that the solution would require moving away from private health insurance, toward a payer health system, similar to other wealthy countries that provide health care to all.
“The solution is effectively to completely overhaul the system and then start from scratch with the national health insurance system,” Verhoef said. “Solutions that depend on trying to regulate the private insurance industry are simply going to fail.”
There is “no way to modestly reform a fundamental flaw in a business model,” Weisbart added. “Their business model is designed to delay, deny and redirect health care we know a much better way: the better way is to build a system on top of the traditional Medicare program. Fix the things that are wrong with Medicare…and then provide that for everyone. »
Moving to a universal health care system A universal health care system would likely cost less than current national health spending, according to a 2020 Academic Analysis – and save tens of thousands of lives every year.